S 1620 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT.PEN ONLY
CTTY OF CUPIsRTINO BU
ILDINGTRICAL PF. IT NO.
6UILDINf.DIVISION APPLICATION/PERMIT w. lAmc`L J 1620
R1111.DINEN'TIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWN ANE: 1'H(1NL: COM'
SIC CONTROLN
• ARCHITI[CI'/FNGN ER: LIC NO: AD R ❑
CONTACT: ��/ (ONE: BUILDING PERMIT INFO
�'S// ❑ Consultant Feelicant(Initial) BLDG IiLE T PLUMB ME H
LICENSED CONTRACTOR'S DECLARATION QTY. ELIT' FEEI hereby affirm Thal I um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
won with Section]II(111)nl Diviainn3ol the Bnsinexa and lM casinos Gdc,a Jm licenceis ! R SIDEaENTIAL
Wp PERMIT ISSUANt
Fz� in full force and c ❑SFDK'1. El KITCHEN REMODIiL
�VV License ,a Lic.6 APPLIANCES-RESIDENTIAL. []ADDITION C3 PLUMBING RE-PIPE
FZu1 Dale
Com mcmr
vsQ6 ❑MULTI-UNIT ❑STRUCTURAL.
A CHITECPS DECLARA [ON
mnd
~'Z I milersmy plans be used as public records PANELS MODIFICATION
rZC UI"T020o AMPS (D INTERIOR [3 CHIMNEY REPAIR
G•~� Lieemed Pralesaifom 201-100AMPg IMPROVEMENT C]SWIMMING POOLS
OWNER-RUILDER DECLARATION
y, OVER I0IIIIAMP3 El BATH RF.MODEI/REPAIR ❑DEMOLITION
Ihereby uflinn thatm 1 aexcntpt fronn
I,,,.the Ctmcmrs License Lies,fur the
3 Q at H following coos."(Section]o3I S,Business and Profesnionx Code:Any city or county SIGNS ELECTRICAL ❑G :�
which requires a permit to construct,alter,improve,demolish,or repair any suuatum
F u'O- pnam its ismance,dwim,uiros the applicant forsuch permit m file asigned statement SPECIAL CIRCUI'UMISC.
�ppp5
a!) that he is licensed purmanuo the provisions of the Conlmatars License Law(Chapter 9 COMMERCIAL
o (commencing with Sector Tonsil of Division Jofthc llusiness and Pr.fesxinm Code)or TEMP.MIUHRORPOLEINST.
I
yy oy that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
XmIL
Section 7031.5 by any applicant l or a perinitsubjcns the ap,herauo a civil penalty of POWER DEVICES El TENANT ❑FOODSERVICE
..w t more than Eve hundred dollars(35110).
71,
Las moment the norm employees with..'a as their sole compensation, SWIMMING POOL ELECTRIC OTHER IMPROVEMENT
❑ grope Y yemp YPens' 11 OTHER
owilldnthe work.anddn,tm.rm is not intendedmoff"od article Seo.0614,Business
tyro and Prnfessiom Cade:The Conlmemw has not apply rs License lam an owner of OUTLEI;S—SWITCHES—FIXTURES
pmpcny who builds or Improves themam,and who does such work himself or through
his osvn employees.provided Wet such improvements am not intended or offered for NEW RESIDENTIAL.ELEC R SQ Fr.
sale.IL however,the buildingor improvement iasold withinoneyear0f completion.the F1'.PLMiR ARTA 5/SQ,FT.
inveactummoir will have the burden of procia,dot hn did not build m ntpmve for par-
Pott1 saleTOTAL
a
❑ I, owner
r ollhe progeny,nm exclusively contracting with licensed contractors m
construct We project(Sec.7014,Business and Professions Coda)no Commdnrs Li-
.se Law diva not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contactors)licutsod pursuant ht the Co.traetads
License Ivw. PERMIT ISSUANCE
❑I am exempt under Sec. .R&P C for this reason
ALTER-DRAIN&VENT-WATER IIIA) VALUATION
Owner Mato
WORKER p COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I hereby al num l.h.penaltyate ret try nuc of following ar Zikeatinns: (�
❑Ihave and will maintain uCeniticnteof Cnnxnno selGinutrc for Workers Compere- DRAINS-PLOOR,ROOP.AVC CONU RIES TYPE CONSTRUCTION
,a .a,as mvided for by Section 3700 of the Lubar Crede,for the perannance of Ne
r whah this permit is lamed. FIXTURLS-PER'TRAP
w I have and will maintain Workers Compensation Insurance,as required by Section
]W.f the laMr Code,for the perfmran on[the wvrk for.1ichtbis permit is iss.ed GAS-L'A.Sys'fEM-I INC.40NT.FTS (H:C.GROUP AI'N
hly Worker a tion (isLtunre or and Policy numbeyptgHan J
Cannon Policy Nn: (..(.(/L �/'T GAS-LA.SYSTEM-OVER 4IRA)
CERTIFICATE'OF EXEMPT ION FROM WORKERS' GRIiASFJINDUSTRL WAS iIN
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be asmplehil if the permit Ls for one hundred dollars($100) 0
or less) GREASE TNAP ANCHECK FEE
I certify that in the performurvenfthe work 6n which this permit is issued,lshall SEWER-SANITARY-SEA,200 IT.
rot employ any perm.in any manner m as m lax.mc whject to the Worker'Camped- ' ERGY PIiE
,z smian lawsof Califomia.Date WATER IIEAT]R WINE 3LECT P
Z Applicant RAGING IEE
NOTICE TO APPLICAN I':11,after making Wis Conneaut of Exemption,you should WATER SYSIIIM/TREA' G OILS FEE O
h > become subjectto the Workers Compenxmo m provisions of the Lubar Code,you most pp
6i ti forthwith comply withsuch provisions or thisperinit shall be deemed revoked. WATER SERVICEq
+ 0
{ryD CONSTRUCTION ItNDLNGn 'NCY NEW RESIUEM'IAL PLMB. PAID
� Ihereby affirm lhoubcm is acnrNwction lendingg a'
agency 65nhe perf.mmnce of [)areR cip
the weak for which this permit Is issued(Sec.app,Civ.C) TOTAL:
w0F' Leaders Name
r Lenders Address TOTAL: 1
y 1 certify that I have mail this application and stove than the aMwe info matin"s BUILDING FEE
F. e,1 correct.l agree to comply win all city and county ordinances and nate laws totaling to QTY. MECHANICAL PERM IT FEE SEISMIC FEE
V Z building canswetier,and hembyauthorix repmnenmtivex of this city to enter upon the
above-mentioned properly for inspection Purryne.s. PERMIT'ISSUANCE �D
Dive)agree.)save,indemnify and keep harmless the Cay el Cupertino against ♦ ELECTRIC PEE,
iabilities.judgmenrs,costs and expenses which may in uny way accrue against said City AMER OR ADD R)MF.CH. PLUMBING FEE 5C
in conseeucnce of be gtaming of his pemtit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI ED ALL NON-L'OINT AIR 14ANDLING UNIT GED 111,010 CFM) MECHANICAL FEE
SOURCE REGULATIONS. 1
AIR HANDLING UNIT(OVER 10,(00 CFM) CONSTRUCT ION TAX
Signature of Applieam/Comeact0r Dam EXHAUS'THOUD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Kflltheapplimumfimma building acupantsmmorhuWlenoannus anterial HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Mamv ode.Chapter 9.12•end the health and Safety
Code,Section 25532(a)1 HEATING UNIT(OVER I0B0m B'FU)
[I Ye, t VE l LAUDS FAN IS INGLE RESH)n PAID punt RaciplM
• Wi 11 the applicant or future building compound use equipment or dev Ices which BOILER—COMP(3HPOR I IO, 1BTU7
emb
it mrdous air commminams as did by the Bay Area Art(Enshly Management (01TOTAL: v
Dlstrad' / BOILER—COME(OVER 100,010 BTU)
❑Yes
I have read the hmardernmaterials resettlements under Chapter 6.95 of the Cali- AIRCONDITIONER r ISSUANCE DATE�
fomia Health&S ny Cole.Sections 25505.25533 and 25534.1..do,. oat it t NEW RESIDENTIAL MECH. SQ.ET,
huildmgdce.an Blyth won t C
or lhorm c must "prior hissuwm ofa Con' fIX
Ow er rnu ri s Date TOTAL: 12 ISSUED BY: ✓ _ �If�
OFFICE